The blog of Ashish Jha — physician, health policy researcher, and advocate for the notion that an ounce of data is worth a thousand pounds of opinion.

Monthly Archives: March 2013

In 2006, Governor Mitt Romney signed Chapter 58 of the Acts of 2006 entitled “An Act Providing Access to Affordable, Quality, Accountable Health Care.” It has been described by many names, including Massachusetts Healthcare Reform (MHR), Romneycare, or simply, as the template for the Affordable Care Act. The goal of the act was straightforward: to ensure near-universal access to health insurance for citizens of the Commonwealth of Massachusetts. The bill quickly led to insurance expansion: by 2010, 94.2% of adults under 65 had health insurance, an 8 percent increase over the 86.6% in 2006. By all accounts, the goals of insurance expansion were met.

But the bill has not been without controversy. There have been two main concerns: first, that the bill did too little to control rising healthcare costs. The cost crisis led to the 2012 bill that many refer to as “Mass Health Reform 2.0” – formally called Chapter 224 of the Acts of 2012. Its focus is to curtail healthcare spending, and while reasonable people have reasons for skepticism about the likelihood of success, that’s a topic for another day.

The second concern was that bringing hundreds of thousands of new people on to the health insurance rolls without a commensurate increase in physician supply would overwhelm the state’s supply of physicians. The logic behind the concern was as follows: health insurance expansion created nearly 400,000 newly insured residents. As these folks rushed in to see primary care physicians, all the empty spots filled up, the primary care offices got overwhelmed, and access for everyone else was diminished. Stories of physician shortages abounded: the Massachusetts Medical Society called the shortage of primary care at a “critical level”, citing its own surveys (which were of poor quality). The Wall Street Journal editorial page ran stories entitled “RomneyCare’s bad outcomes keep coming”, citing the same MMS statistics.

So, for a hypothetical 80 year old woman we will call Ms. Jones, who has congestive heart failure, getting into her PCP was harder. She used to see her PCP every 2 months, but after Mass Health Reform, had to wait longer between visits. And, when her breathing worsened one night, instead of getting seen by her PCP the next morning, she had to go to the emergency room and ended up getting admitted. Indeed, people worried that for the most vulnerable patients, those who rely on primary care to stay out of the hospital, Mass Health Reform decreased access, made their lives worse, and led to unnecessary hospitalizations and worse outcomes.

The concerns over insurance expansion without adequate provider expansion, of course, become that much more salient in the context of the Affordable Care Act. If Massachusetts, with its large supply of physicians and a reasonably high insured rate prior to health reform, could suffer broad shortages that hurt vulnerable populations, the rest of the nation is surely in trouble. This was the scenario played out repeatedly in the political debates of 2012 when Mitt Romney was running for the Republican nomination. Not surprisingly, these discussions were generally data-free. We felt that empirical input would be helpful. Whether Massachusetts residents suffered because of the reported shortage of primary care was a serious question that needed to be addressed with real data, and we set out to do so.

To determine if Massachusetts residents were negatively affected, we examined rates of preventable hospitalizations, those that result directly from diminished access to effective primary care, before and after health reform kicked in. We focused on older adults, the Medicare fee-for-service population, who rely on primary care, hypothesizing that if their access to primary was curtailed, they would be susceptible to these preventable admissions. We studied Massachusetts from 2005 through 2010, and used the rest of the New England states as controls. We figured any effect would be particularly pronounced among those over 80 years of age, who might be particularly vulnerable to disruptions. Finally, we thought that the counties within Massachusetts where the insurance uptake was the greatest, and therefore where the biggest surge of new patients to PCPs might occur, would see the biggest negative effects.

The Impact: So What Happened?

So what did we find? Not much. Our study was well powered to detect even small differences – and we found no negative impact of MHR at all. In fact, contrary to our hypothesis, rates of preventable hospitalizations fell somewhat more rapidly in Massachusetts after the reform than it did in control states (see Exhibit 3 of the paper in Health Affairs). The effect was small and whether it was due to the reform or some other factor is unclear. What is clear is that if Massachusetts Health Reform did lead to a negative spillover on the previously insured, it was not substantial enough to have a deleterious effect on their outcomes. In every group we examined, Massachusetts improved as rapidly or even more so as the control states.

So are we done worrying about Massachusetts?

Does this mean that we should table the concerns about MHR having a negative effect on the previously insured? Not quite yet. It is possible that older, vulnerable patients saw their primary care physicians less often, or maybe they had extra visits to the emergency room and received more tests and procedures as a result of having less time with their PCPs. These are ongoing analyses and we expect to have answers soon. However, at least in terms of the bottom line, preventable hospitalizations, the events you’d worry about the most if there was restriction on access to primary care, there was no negative effect.

Implications for the Affordable Care Act:

If older Americans in Massachusetts did not experience clinically meaningful harms as a result of insurance expansion, what does this mean for the 49 other states that are about to expand their pools of the insured over the upcoming years? It is not straightforward to translate the Massachusetts experience to Texas, where a quarter of the population is uninsured and there are fewer primary care physicians per capita. Might insurance expansion there or in Florida have much bigger effects? Maybe. However, our findings suggest that our healthcare system is far more resilient than we think. Static notions of capacity may be inadequate. Massachusetts was able to absorb the newly insured population with little disruption and I suspect many other states will as well.

However, maybe in states like Texas and Florida, where the impact of insurance expansion will be more substantial, we could also think more creatively. Instead of trying to manufacture more primary care physicians, a long and expensive endeavor, we should think harder about how to better use the trained professionals we have. We need to rethink our “scope of practice” rules that limit the ability of well-trained Physician Assistants and Nurse Practitioners from caring for patients. We need to think about how to use health information technology more creatively. Virtual visits and telehealth can make current providers more productive, allowing them to care for more patients by more effectively triaging who can be seen virtually and who needs to be seen in person. Again, reimbursement and regulatory hurdles slow us down, but if state and federal policymakers are smart, we can fix these issues.

Finally, and most importantly, we need to carefully monitor how insurance expansion plays out in the 49 other states and the District of Columbia. We need clear metrics to track not just the impact on the previously uninsured (whether they took up insurance or not) but also on the previously insured. The truth is, while we may split people into the uninsured and the insured, we are all part of the same healthcare system – and what happens to one group likely affects all of us.